Inspection on 04/05/05 for Walsall Road, 836

This inspection was carried out on 4th May 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Walsall Road, 836 17/08/07

Walsall Road, 836 10/11/06

Walsall Road, 836 18/11/05

Walsall Road, 836 16/11/04

Walsall Road, 836 08/06/04

Walsall Road, 836 04/02/04

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

10 Whitfield Avenue

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOME ADULTS 18-65 Walsall Road, 836 836 Walsall Road Great Barr Birmingham B42 1JN Lead Inspector Gerard Hammond Unannounced 4 May 2005 & 21 June 2005 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Walsall Road, 836 E54 S16938 Walsall Road 836 V229574 040505 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Walsall Road, 836 Address 836 Walsall Road Great Barr Birmingham West Midlands B42 1JN 0121 358 0009 0121 358 0009 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Milbury Care Services Limited Mrs Lisa Hannah Carey Care Home 4 Category(ies) of Younger Adults, Learning Disability (4) registration, with number of places Walsall Road, 836 E54 S16938 Walsall Road 836 V229574 040505 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1. Residents must be aged under 65 years with a learning disability. 2. The home can continue to accommodate one named service user over 65 with a learning disability. 3. That 836 Walsall Road apply for variation on behalf of future service users who reach the age of 65. 4. That details regarding how the specific care and social needs of people over the age of 65 will be met must be included in the service users plan. 5. Future admissions, and the Statement of Purpose be amended to reflect the age of service users accommodated. Date of last inspection 16 November 2004 Brief Description of the Service: 836 Walsall Rd. is registered to provide accommodation care and support for four adults with learning disabilities and is run by Milbury Care Services. The house is a detached bungalow and lies back from the main A34 Birmingham to Walsall road, being accessed via a good service road. It is situated in the Great Barr area of Birmingham, a short walk away from the Scott Arms shopping centre. The house is well served by public transport and conveniently located for a wide range of community facilities including shops, pubs, food outlets, libraries, places of worship and parks. Residents all have single bedrooms containing wash hand basins. There is a bathroom with facilities for assisted bathing, and a separate w.c. The lounge / dining room is situated at the front of the house. There is a small office, kitchen and separate laundry room, and both the front and rear of the property is accessible to wheelchair users. The pleasant rear garden is enclosed and private. There is parking at the front of the property, both on and off road. Walsall Road, 836 E54 S16938 Walsall Road 836 V229574 040505 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over two visits. Direct observation and sampling of records, including personal files and care plans, was undertaken for the purposes of compiling this report. The inspector met all the residents, and formally interviewed the Home Manager and Deputy Manager. The Organisation’s Operations Manager was also in attendance on the second visit. What the service does well: What has improved since the last inspection? What they could do better: Good work already done on care planning needs to be further developed in such a way that makes it possible to measure improvements and progress that has been made. This can be achieved by setting some goals for each of the residents, and then taking a look at what has been successful and what needs to be changed. Personal files need a good “tidy up” so that only current and relevant information is kept on them. Getting rid of old material will make it much easier to find information that is needed to support people’s care. Walsall Road, 836 E54 S16938 Walsall Road 836 V229574 040505 Stage 4.doc Version 1.40 Page 6 Some work needs to be done to extend the opportunities that residents have for activities, both in and out of the home. This will have a positive effect on the range and quality of their educational, social and leisure experiences. The commendable efforts made by staff to improve the communication opportunities for residents need to be encouraged, supported and further developed. This is a challenge for the wider organisation to address how it can enhance the capacity of its workforce to take this forward. Arrangements for formal supervision of staff and for staff group meetings need to improve, and some practices relating to Health and Safety issues need to be “tightened up”, to ensure that tasks required get done. There are also some shortfalls in staff training, notably in the Protection Of Vulnerable Adults From Abuse, and these must be addressed. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Walsall Road, 836 E54 S16938 Walsall Road 836 V229574 040505 Stage 4.doc Version 1.40 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection Walsall Road, 836 E54 S16938 Walsall Road 836 V229574 040505 Stage 4.doc Version 1.40 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1, 2, 5 Information is available to assist prospective residents to make an informed choice about the service available at 836 Walsall Rd. Residents’ needs have been assessed and relevant information recorded on their personal files. Contracts require further amendment to make them fully compliant with Standard 5.2 EVIDENCE: The Statement of Purpose has been amended in accordance with requirements made at the last inspection. Efforts have been made to produce the information in alternative formats suitable for people with learning disabilities, but it has to be acknowledged that no one format will suit all prospective residents. A judgement has to be made at any given time with regard to establishing the best way of sharing relevant information, in accordance with each person’s communication needs and level of understanding. There have been no new admissions since the last inspection, and the personal files of each resident contain a wealth of assessment information. See the following section relating to care plans also, in this regard. Another requirement made at the last inspection relating to residents’ contracts has been met in part. This should now be finalised so that all contracts comply with Standard 5.2. Walsall Road, 836 E54 S16938 Walsall Road 836 V229574 040505 Stage 4.doc Version 1.40 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6, 7, 9 Good work already begun on developing care plans needs to be consolidated, so that plans reflect each person’s individual goals. Residents are supported and encouraged to make decisions about day-to-day issues. Improving the capacity of staff members to communicate in alternative ways would enhance this further. Responsible risk taking is recognised and encouraged, but this needs to be linked more directly with individual care plans. EVIDENCE: The development of individual care plans is a work in progress. There is plenty of evidence of good work being undertaken by the care team in terms of trying to introduce person-centred approaches, as well as implementing the Organisation’s new care plan format, and this should be acknowledged. However, there is still work to be done. Current files contain a high volume of detailed information, in keeping with the complex nature of residents’ care needs. There is a real challenge for staff in deciding how this information should be maintained, and presented in such a way that renders it accessible and useful. The core of individuals’ care plans must be effective working documents – they are the “tools of the trade”. This is especially important Walsall Road, 836 E54 S16938 Walsall Road 836 V229574 040505 Stage 4.doc Version 1.40 Page 10 when the Home is reliant on significant support from agency staff. Files require a substantial overhaul: material that is not current should be disposed of or archived as appropriate. Statements of need should be reviewed and updated: these are the basis for informing what needs to be included in each care plan. Care plans should set goals, which can be evaluated subsequently at review. Reviews of individuals’ total care packages should take place at least every six months. Written records should be kept, indicating who takes part and how decisions have been made. In the same way, current risk assessments are in need of some attention. It was noted that the index of one resident’s risk assessments did not match the contents of the file. This is potentially confusing and indicative of the point made earlier about managing information effectively. Risk assessments should be cross-referenced to the component(s) of the care plan(s) to which they relate, and vice versa. They should also be reviewed in conjunction with care plans, as indicated above. These issues were discussed with the Manager, and it was suggested that adopting a person-centred approach such as ELP (Essential Lifestyle Planning) might usefully supplement the good work she has already instigated. Staff demonstrate a very positive attitude towards enabling residents in their day-to-day interactions, offering choices and encouraging them to make decisions where possible. Their ability to do this could be enhanced by improving the team’s capacity to communicate non-verbally. Consideration should be given as to how this might be achieved. Walsall Road, 836 E54 S16938 Walsall Road 836 V229574 040505 Stage 4.doc Version 1.40 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 11, 12, 13, 15, 16, 17 Residents have opportunities for personal development, appropriate activities and to access the local community. However, work needs to be undertaken to analyse these activities appropriately, so that the range, quality and frequency of opportunities available can be properly assessed. Contact with families and friends is positively facilitated and actively supported. Staff respect residents’ rights and encourage their independence. Residents have access to a balanced diet and can make positive choices about what they eat. EVIDENCE: As identified at the time of the last inspection, a considerable amount of work has been devoted to exploring ways of developing communication opportunities for residents. This should be continued and extended as much as possible, recognising that the ability to communicate effectively underpins all other activities. People living in the house also have other opportunities for skill development, for example by being encouraged to be actively involved in Walsall Road, 836 E54 S16938 Walsall Road 836 V229574 040505 Stage 4.doc Version 1.40 Page 12 domestic tasks, and undertaking other activities in community settings. Routines and “house rules” promote this positively, as do the actions of members of staff. All residents access organised day activities at local centres for part of the week. The relationship with some of these establishments is longstanding and clearly valued highly. Personal records give evidence of other activities in both home and community settings. Previous inspection reports have highlighted concerns about the range, quality and frequency of activity opportunities, and requirements made that this should be evaluated. This remains a concern, though some efforts have been made to develop opportunities and make improvements. It was specifically recommended that this exercise should include establishing what the purpose of scheduled activities should be, in order to make informed decisions about the effectiveness of undertaking each particular activity. There was little or no evidence that this has been undertaken. An effective analysis of residents’ activities can serve several purposes. By “mapping” activities across a reasonable period of time (say, 3-6 months), an accurate picture of some quality of life issues can be gained. This can then form part of an organisation’s quality assurance and monitoring programme (see Standard 39 also). The analysis can also highlight issues that Managers may need to consider. A good example of this might be: - do residents only undertake certain activities with certain members of staff and are there particular patterns of activity that may need to be considered? How are decisions about what activities are undertaken (and where) actually made, and in whose interests? There is a purpose in proposing that the purpose of activities be considered and made explicit. Any given activity might be to learn, practise or maintain particular skills. The activity might be recreational, or therapeutic, or “just for fun” – or indeed any combination of any or all of these things. Deciding this should be directly linked to goal setting in individuals’ care plans. This task should provide excellent opportunities for residents to exercise real choices, and for practising person-centred approaches. It is therefore a requirement of this inspection that a serious analysis of residents’ activity opportunities be undertaken as a matter of some priority, so that a clear baseline can be established to inform future planning. This will be assessed in detail at the next inspection. It is evident from residents’ records, previous reports and direct observation that family contact is both facilitated and actively supported wherever possible. The mother of one resident visited on the day of the inspection, and was supported to accompany her son for a medical appointment. She spoke highly Walsall Road, 836 E54 S16938 Walsall Road 836 V229574 040505 Stage 4.doc Version 1.40 Page 13 of the support that she herself received, and commended staff for the care they give to her son. Menus and records of food actually taken were seen. There is a rolling sixweek menu in operation, with additional choices available on a daily basis, should residents so desire. The small size of the Home facilitates this without difficulty. The stock of food was seen to be varied and to include fresh produce. It was noted that records showing that residents took a “packed lunch” should in future indicate specifically what is in this. Walsall Road, 836 E54 S16938 Walsall Road 836 V229574 040505 Stage 4.doc Version 1.40 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18, 19 Staff try hard to support residents according to their wishes, and treat them with kindness, warmth and respect. Residents’ healthcare needs are generally met, but some shortfalls identified at the last inspection remain outstanding and must now be dealt with. EVIDENCE: Basic standards of physical care are high and it is clear that residents are well cared for. Everyone is dressed smartly and it is evident that staff support residents well in taking a pride in their appearance, and that this is appreciated. Personal care was seen to be delivered in a warm and friendly manner, and members of staff are appropriately polite and respectful in their dealings with residents. Comments have been made elsewhere in this report with regard to improving communication opportunities for residents. This would also enhance the capacity of members of staff to support residents according to their wishes, where these cannot be verbally expressed. The Organisation should look at ways that the staff team can be supported to achieve this. A number of requirements were made at the time of the last inspection in relation to residents’ healthcare needs, and some of these have now been met. In particular, it was identified that there was a need for staff to receive training Walsall Road, 836 E54 S16938 Walsall Road 836 V229574 040505 Stage 4.doc Version 1.40 Page 15 in supporting people with visual impairment, and this has now been delivered to seven of the team. Outstanding dental and chiropody appointments have now been attended to. There is evidence on people’s records that access to members of the multi-disciplinary team is facilitated according to individual need. A requirement relating to the monitoring of residents’ bowel care remains outstanding, and this should now be dealt with as a matter of priority. Practice with regard to the storage, handling and administration of medicines was seen to meet required standards in full at the time of the last inspection, and was not assessed on this occasion. Walsall Road, 836 E54 S16938 Walsall Road 836 V229574 040505 Stage 4.doc Version 1.40 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22, 23 It is difficult to judge fully whether or not residents feel that their views are listened to and acted on appropriately, but staff try hard to be sensitive to residents’ needs. The capacity of the team to protect residents from abuse effectively would be enhanced if all members received appropriate training, as required. EVIDENCE: The organisation has an appropriate complaints procedure: no complaints have been received at the Home since the last inspection. Fully assessing the outcome of this standard is rendered difficult because it is not possible to judge with complete accuracy whether or not these residents feel that their views are listened to and acted on. Their capacity to understand the full implications of their rights to complain, or to make full use of the processes open to them, is variable. For the most part, they rely on the staff looking after them to be sensitive to changes in demeanour, behaviour or “body language” as indicators that something might be amiss, and to respond appropriately. Staff deal with this to the best of their ability in the prevailing circumstances. A requirement left at the time of the last inspection that members of staff who had not received training in the Protection of Vulnerable Adults from Abuse should do so, has not yet been met. There is the capacity, within “Communication Passports” being developed for everyone living in the Home, to record information about known indicators of discomfort or distress as exhibited by each person. It is recommended that this be completed, as a valuable addition to the strategy for ensuring their protection. Walsall Road, 836 E54 S16938 Walsall Road 836 V229574 040505 Stage 4.doc Version 1.40 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24, 27, 30 The house provides residents with an environment that is homely, comfortable and safe. Toilet and bathroom provision is sufficient, and shortly to be upgraded. The Home is kept clean and tidy, and good standards of hygiene maintained. EVIDENCE: 836 Walsall Road has a pleasant and homely feel to it. The house is generally well maintained, and issues brought to the attention of the Organisation’s maintenance team tend to be dealt with reasonably expediently. Fixtures, furnishing and fittings are of a good standard, and residents’ own rooms are all individual in design, and personal to the occupant. Requirements made at previous inspections have generally been dealt with, where this involves refurbishment or repair. However the Organisation providing care support does not own the building, so issues involving major structural work tend to be rather more complex. The house could not be said to be extensively spacious, and room sizes are not up to current standards. Although the house is wheelchair accessible, door widths and general space is limited. Regrettably, the layout and position of the house does not lend itself to Walsall Road, 836 E54 S16938 Walsall Road 836 V229574 040505 Stage 4.doc Version 1.40 Page 18 further adaptation, so additional improvements to the overall design are likely to prove extremely difficult, if not impossible. Substantial improvements are now scheduled for the bathroom, and these should be complete by the end of August. The Home is kept clean and tidy, and a good standard of hygiene maintained. Walsall Road, 836 E54 S16938 Walsall Road 836 V229574 040505 Stage 4.doc Version 1.40 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33, 35, 36 Recruitment to vacant posts has proved problematic in the past, and the Home has been over-reliant on agency staff, but there are indications that this is set to improve shortly. An up to date training and development assessment is required to assess whether or not the workforce is appropriately trained. Some efforts have been made to address previously identified shortfalls. Staff are generally well supervised on a day-to-day basis, but formal arrangements for staff group meetings, and for individual supervision need to be improved upon. EVIDENCE: At the time of the inspection, it was advised that there were 105 hours vacant (per week) but that three new members of staff had been recruited, and were due to commence shortly, subject to appropriate clearance. Of the agency cover being used, it was further advised that about 85 of this was provided by personnel who were used to working at the Home, so that the effect on continuity of care was kept to a minimum. An up to date staff training and development assessment was not available on the day of the unannounced inspection, and a requirement was made that this should be forwarded to CSCI. This should indicate what training each member Walsall Road, 836 E54 S16938 Walsall Road 836 V229574 040505 Stage 4.doc Version 1.40 Page 20 of staff has received, and when refreshers or other training is due. It should also indicate when outstanding training is scheduled for, and who is to deliver it. Records for staff group meetings and for formal (individual) supervision sessions were examined. The Standard indicates that, in both cases, the frequency of such meetings should be at least six times per year, with written records being maintained. Staff meeting frequency has improved of late, but the frequency still falls below the standard required. Individual supervision is more variable, with some staff members close to, or achieving the standard, while others are significantly short. It is recognised that there may be some difficulties in scheduling this for some people (e.g. night staff), but appropriate supervision should not be seen as an optional extra. It is especially important in a Home that has had to rely significantly on agency staff provision. Walsall Road, 836 E54 S16938 Walsall Road 836 V229574 040505 Stage 4.doc Version 1.40 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 39, 42 The Organisation must ensure that the new quality assurance and monitoring system to be implemented shortly takes full account of residents’ communication needs, so that their views can be represented appropriately. Some practices with regard to promoting residents’ health and safety are in need of attention to ensure that tasks required are actually carried out and recorded appropriately. EVIDENCE: The Organisation is in the process of introducing a new system for quality assurance and monitoring across all of its homes, and it is anticipated that this should be in place by the end of August 2005. It is important that close attention is paid as to how residents’ views are sought, taking particular account of the issues raised earlier in this report, with regard to meeting their communication needs effectively. A clear assessment of the quality of life experienced by the people who use this service should also include an analysis of their activity opportunities, as indicated earlier. This will be examined in greater detail at the Home’s next inspection. Walsall Road, 836 E54 S16938 Walsall Road 836 V229574 040505 Stage 4.doc Version 1.40 Page 22 Records relating to fire safety were examined: the alarm system and fire extinguishers had been serviced, and fire drills carried out as required. However, there were significant gaps in the recording of weekly tests of both the fire alarm and the emergency lighting systems. These omissions must be dealt with as a matter of priority: important tasks of this nature should be clearly delegated to named individuals, with contingency arrangements in place to cover any absence. The fire risk assessment was shown to have been reviewed, but was not signed. A requirement was made at the last inspection that external door locks needed reviewing to ensure their suitability for facilitating rapid exit in the event of fire. Advice was sought from the local Fire Officer and new locks have now been fitted. The COSHH file was seen, and relevant products observed to be securely stored, as required. Portable appliance testing of electrical equipment has been carried out, and the Home’s hard wiring certificate is in date. The landlord’s gas safety certificate is now due for renewal. Testing of temperatures at all water outlets is shown to have been carried out and recorded appropriately as required. Walsall Road, 836 E54 S16938 Walsall Road 836 V229574 040505 Stage 4.doc Version 1.40 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 3 x x 2 Standard No 22 23 ENVIRONMENT Score 2 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 2 x 2 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x x 3 x x 3 Standard No 11 12 13 14 15 16 17 2 2 2 x 3 3 3 Standard No 31 32 33 34 35 36 Score x x 2 x 2 2 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Walsall Road, 836 Score 3 2 x x Standard No 37 38 39 40 41 42 43 Score x x 2 x x 2 x E54 S16938 Walsall Road 836 V229574 040505 Stage 4.doc Version 1.40 Page 24 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 5 Regulation 5 (1 b-c) Requirement Residents contracts must be amended so as to comply with Standard 5.2 Outstanding since 31.03.05 Review care plans and set targets with measurable outcomes. Ensure that records of reviews show who takes part, and how decisions are made. Residents whole care plans should be reviewed every six months at least. Review risk assessments in conjunction with care plans. Ensure that risk assessments are appropriately cross-referenced with relevant care plans, and that indeces are current and accurate. Review and develop the range of activity opportunities available to residents. Outstanding since 14.01.05 Ensure that residents bowel care is appropriately monitored and that care plans are written to reflect this. This should include clear guidance with regard to action required by staff if bowel movements do not take place, what constitutes a safe period Timescale for action 31 August 2005 31 August 2005 2. 6 15 3. 9 13 (4c) 31 August 2005 4. 11-13 16(2 m-n) 31 August 2005 Within 3 days 5. 19 12 (1a) Walsall Road, 836 E54 S16938 Walsall Road 836 V229574 040505 Stage 4.doc Version 1.40 Page 25 6. 35 18 (1c) 7. 39 24 (1-3) 8. 42 13 (4) between movements and who can be contacted for further advice or assistance. Outstanding since 07.01.05 Submit to CSCI a detailed staff development and training assessment. This should clearly indicate the training that each staff member has received, and identify when refreshers or further training is due. It should also indicate when training is scheduled and who is to deliver it. Implement the new quality assurance system to take account of residents’ communication needs, so as to represent their views appropriately Ensure that weekly checks are conducted on the fire alarm and emergency lighting systems, and appropriate records maintained. Ensure that the Home’s Fire Risk Assessment is reviewed, signed and dated. 31 August 2005 31 August 2005 Within one week RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard Good Practice Recommendations Walsall Road, 836 E54 S16938 Walsall Road 836 V229574 040505 Stage 4.doc Version 1.40 Page 26 Commission for Social Care Inspection Birmingham & Solihull Local Office 1st Floor, Ladywood House 45-46 Stephenson Street Birmingham, B2 4UZ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Walsall Road, 836 E54 S16938 Walsall Road 836 V229574 040505 Stage 4.doc Version 1.40 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!